Health inspection·March 19, 2024

F684 §483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person- centered care plan, and the residents' choices

F689 42 CFR §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311 Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The California Department of Public Health (CDPH) received a facility reported incident on 2/5/2024 indicating on 2/4/2024, the facility received a telephone call from a nearby restaurant informing the facility, a resident (Resident 1) was at the restaurant. Staff immediately went to pick up the resident and brought her back to the facility. Charge nurse immediately completed a full-body assessment, and the resident was noted to not have any injuries. On 2/12/2024, an unannounced investigation was conducted at the facility. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Elopements and Wandering Residents”, which indicated the facility was to ensure residents at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. 2. Implement Resident 1’s care plan, which indicated the resident would be closely monitored. As a result, Resident 1 eloped from the facility and was later found at a nearby restaurant two hours after last seen by facility staff. A review of Resident 1’s Admission Record indicated Resident 1, was a 70 year-old female, originally admitted to the facility on 1/9/2024, with diagnoses that included but not limited to dementia (impaired ability to remember, think, or make decisions) and history of falls. A review of Resident 1’s Minimum Data Set ([MDS]- a standardized resident assessment and care planning tool), dated 1/16/2024, indicated Resident 1’s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 1 required moderate assistance when putting on clothes, performing personal hygiene, bathing, putting on footwear, and required supervision when eating. A review of Resident 1’s Care Plan titled, “Risk for Wandering/ Elopement Identified related to Cognitive impairments and Dementia”, initiated 1/12/2024, indicated the facility had a risk binder for staff to check and identify residents that were “high risk of elopement” and for them to “closely monitor and know resident whereabouts during their shift”. The Care Plan indicated that the facility’s goal was to maintain Resident 1 ‘s safety. A review of Resident 1’s Nursing Progress Note, dated 2/4/2024, indicated Resident 1 was last seen by Licensed Vocational Nurse (LVN) 2 and Certified Nurse assistant (CNA) 1 “leaving [Activity Room A] and heading to her room” at 5:30 p.m. (on 2/3/2024). The note indicated the facility was notified, at 7:50 p.m., that Resident 1 was at a restaurant, and LVN 2 realized Resident 1 was “missing”. The note indicated LVN 2 accompanied Resident 1 back to the facility at 8:05 p.m. During an interview, on 2/12/2024, at 3:12 p.m., with CNA 1, CNA 1 stated she had 12 other residents to care for that day and was assigned two residents who required constant attention and redirection (Resident 1 and Resident 2). CNA 1 stated she was passing out trays and noticed Resident 1’s tray was not in the meal holding cart, so she assumed Resident 1 would receive her tray in Activity Room A. CNA 1 stated she could not ensure the tray was delivered because Resident 2 had called CNA 1 for help about six times within that hour. CNA 1 stated there were two other CNAs assigned to watch residents in Activity Room A but the CNAs did not know where Resident 1 went. CNA 1 stated on 2/3/2024, she was very busy and last saw Resident 1 at 5:50 p.m., in Activity Room A. CNA 1 stated she did not realize the resident was missing until Registered Nurse (RN) 2 notified her around 7:50 p.m. CNA 1 stated if she was not busy, she would have been able to round (the act of checking on the residents) on all of her residents to ensure Resident 1 was still in the facility. During an interview, on 2/12/2024, at 3:47 p.m., with the Director of Staff Development (DSD), the DSD stated residents identified as high risk for falls, and elopement were encouraged to stay in Activity Room A, where two CNAs were assigned to watch them. The DSD stated if an ambulatory (ability to walk) resident wanted to leave Activity Room A, then he or she could do so without supervision, unless resident had a one-to-one supervision order. The DSD stated staff was supposed to monitor/supervise residents every two hours for safety. During an interview, on 2/12/2024, at 4:20 p.m., with LVN 1, LVN 1 stated the facility’s normal practice to prevent residents from eloping was to first identify residents at risk for elopement by referring to the “elopement risk binder”. LVN 1 stated it was expected for the nursing staff to also provide “frequent visual checks” on residents at risk for elopement, at least every thirty minutes, or within the hour. LVN 1 stated rounding on high-elopement-risk residents every two hours was not sufficient. LVN 1 stated it was important to know the whereabouts of the high-risk residents because they were more likely to elope. LVN 1 stated if a high-elopement-risk resident was to leave Activity Room A, the resident would require supervision. LVN 1 stated if a resident was to elope, he or she could get hurt, or “get their hands on drugs”. During an interview, on 2/12/2024, at 4:38 p.m., with the Director of Nursing (DON), the DON stated the facility identified residents at risk for elopement and ensured the resident was monitored in Activity Room A by CNAs. The DON stated he expected nursing staff to round on residents that were at risk for elopement “at least every hour” to prevent the residents from falling, maintain safety, and to prevent elopement. The DON stated, “We could have kept a closer eye on her (Resident 1). The DON stated 5:50 p.m. to 7:50 p.m. was a long time to not know where the resident [Resident 1] was. If residents elope, there is a potential for a resident to go out on the street and get injured. I cannot say that we provided adequate supervision [for Resident 1]. We could have done a better job at monitoring [Resident 1] if we had done more observations.” A review of the facility’s Policy and Procedure (P&P), titled, “Elopements and Wandering Residents”, dated 4/5/2023, indicated that the facility was to ensure residents who are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Elopements and Wandering Residents”, which indicated the facility was to ensure residents at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. 2. Implement Resident 1’s care plan, which indicated the resident would be closely monitored. As a result, Resident 1 eloped from the facility and was later found at a nearby restaurant two hours after being last seen by facility staff. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.